Requirements to successfully complete PALS:

The American Heart Association released new resuscitation science and treatment guidelines on October 19, 2010. The new AHA Handbook of Emergency Cardiac Care (ECC) contains these 2010 Guidelines.The 2010 PALS Provider Manual is not yet available. This interim study guide will provide you with additional study information. Requirements to successfully complete PALS: Completed PALS Pretest is required for admission to the course. Score 84% on the multiplechoice posttest. You may be allowed to use your ECC Handbook & notes. You must be able to: Use the PALS rapid cardiopulmonary assessment Demonstrate effective infant and child CPR Use an AED on a child Provide safe defibrillation with a manual defibrillator Maintain an open airway Confirmation effective ventilation Address vascular access State rhythm appropriate drugs, route and dose Understand the consideration of reversible causes

You will need to know: CPR/AED: foundation for PALS Arrhythmias (identify): Sinus Rhythm (SR) Sinus Bradycardia (SB) Sinus Tachycardia (ST) Supraventricular Tachycardia (SVT) Ventricular Tachycardia (VT) Ventricular Fibrillation (VF) Pulseless Electrical Activity (PEA) Asystole Normal Respiratory Rate (ECC Handbook p. 74) Age Rate Infant 30 60 Toddler 24 40 Preschooler 22 34 Schoolage 18 30 Normal Heart Rate (ECC Handbook p. 74) Age Sleeping Awake <3 months 80 205 3 months 2 years 75 190 2 10 years 60 140 10 + years 50 100 Hypotension by Systolic Blood Pressure (SBP) (ECC Handbook p. 74) Age SBP < 1 month < 60 1 month 1 year < 70 1 10 years < 70 + (2 x age in years) 10+ years < 90 Hypotension + signs of poor perfusion = decompensated shock (ECC Handbook p. 74) AmericanHeartClasses.com CPR 3G (877) 3114CPR (4277) 2

Differential Diagnosis H s and T s, Seek & Treat Possible Causes, Reversible Causes, PATCH MD 6Hs (Spacing separations may help as a memory aid) Hypo xia Hypo volemia Hypo thermia Hypo glycemia Hypo /hyper kalemia Hydrogen ion (acidosis) 5 Ts T amponade T ension pneumothorax T oxins poisons, drugs T rauma T hrombosis coronary (AMI), pulmonary (PE) Rapid Cardiopulmonary Assessment and Algorithms This is a systematic headtotoe assessment used to identify infants and children in respiratory distress and failure, shock and pulseless arrest. Algorithms are menus that guide you through recommended treatment interventions. Know the following assessment because it begins all PALS case scenarios. The information you gather during the assessment will determine which algorithm you choose for the patient s treatment. After each intervention you will reassess the patient again using the headtotoe assessment. *** General appearance: Level of consciousness: A= awake V= responds to verbal P= responds to pain U= unresponsive Overall color: good bad Muscle tone: good floppy 3

*** Assess ABCs: (Stop and give immediate support when needed, then continue with assessment) Airway: Open and hold with head tiltchin lift Breathing: Present or absent Rate: normal slow fast Pattern: regular irregular gasping Depth: normal shallow deep Sound: stridor grunting wheezing Exertion: nasal flaring sternal retractions accessory muscle use Circulation: Central pulse: present absent Rate: normal slow fast Rhythm: regular irregular QRS: narrow wide *** Perfusion: Central pulse versus peripheral pulse strength: equal unequal Skin color, pattern and temperature: normal abnormal Capillary refill: normal abnormal (greater than 2 seconds) Liver edge palpated at the costal margin normal dry below costal margin (fluid overload) *** Check: Systolic BP (normal or compensated): acceptable for age hypotensive Urine output: normal= 1 2cc/kg/hr, (infants and children), 30cc/hr (adolescents) adequate inadequate *** Classify the physiologic status: Stable: Unstable: Respiratory distress: Respiratory failure: needs little support; reassess frequently needs immediate support and intervention increased rate, effort and noise of breathing; requires much energy slow or absent rate, weak or no effort and is very quiet AmericanHeartClasses.com CPR 3G (877) 3114CPR (4277) 4

Compensated shock: SBP is acceptable but perfusion is poor: central vs. peripheral pulse strength is unequal peripheral color is poor and skin is cool, capillary refill is prolonged Decompensated shock: Systolic hypotension with poor or absent pulses, poor color, weak compensatory effort *** Apply appropriate treatment algorithm: Bradycardia with a Pulse Tachycardia with Adequate Perfusion Tachycardia with Poor Perfusion Pulseless Arrest: VF/VT Asystole/PEA Advanced Airway A cuffed or uncuffed Endotracheal Tube (ET) may be used on Infants and children. ECC Handbook p. 87 To estimate tube size: Uncuffed: (Age in years 4) +4 Example: (4 years 4) = 1 + 4 = 5 Cuffed: (Age in years 4) +3 Example: (4 years 4) = 1 + 3 = 4 Immediately confirm tube placement by clinical assessment and a device:!clinical assessment: Look for bilateral chest rise. Look for water vapor in the tube (if seen this is helpful but not definitive). Listen for breath sounds over stomach and the 4 lung fields (left and right anterior and midaxillary).!devices: EndTidal CO2 Detector (ETD): if weight > 2 kg Attach between the ETT and BVM: Litmus paper center should change color with each inhalation and each exhalation. Original color on inhalation = O2 is being inhaled: expected. Color change on exhalation = Tube is in trachea. Original color on exhalation = Litmus paper is wet: replace ETD. Tube is not in trachea: remove ET. Cardiac output is low during CPR. 5

Esophageal Detector (EDD): if weight > 20 kg and in a perfusing rhythm (Resembles turkey baster) Compress the bulb and attach to end of ETT: Bulb inflates quickly= Tube is in the trachea. Bulb inflates poorly= Tube is in the esophagus. * No recommendation for its use in cardiac arrest.!when sudden deterioration of an intubated patient occurs, immediately check: Displaced: Obstruction: Pneumothorax: Equipment: ET tube is not in trachea or has moved into a bronchus (right mainstem most common) Consider secretions or kinking of the tube Consider chest trauma, barotrauma or noncompliant lung disease Check oxygen source, BVM and ventilator PALS Medications During Arrest: Epinephrine: catecholamine ECC Handbook p. 92 Increases heart rate, peripheral vascular resistance and cardiac output; during CPR increases myocardial and cerebral blood flow. IV/IO: 0.01 mg/kg of 1:10 000 solution (equals 0.1 ml/kg of the 1:10 000 solution); repeat q. 3 5 min Antiarrhythmics: Amiodarone: atrial and ventricular antiarrhythmic ECC Handbook p. 89 Slows AV nodal and ventricular conduction, increases the QT interval and may cause vasodilation. VF/PVT: IV/IO: 5 mg/kg bolus Perfusing VT: IV/IO: 5 mg/kg over 2060 min Perfusing SVT: IV/IO: 5 mg/kg over 2060 min Max: 15 mg/kg per 24 hours hypotension, Torsade; halflife is up to 40 days AmericanHeartClasses.com CPR 3G (877) 3114CPR (4277) 6

Lidocaine: ventricular antiarrhythmic to consider when amiodarone is unavailable ECC Handbook p. 94 Decreases ventricular automaticity, conduction and repolarization. VF/PVT: Perfusing VT: Infusion: IV/IO: 1 mg/kg bolus q. 515 min IV/IO: 1 mg/kg bolus q. 515 min 2050 mcg/kg/min neuro toxicity seizures Magnesium: ventricular antiarrhythmic for Torsade and hypomagnesemia ECC Handbook p. 94 IV/IO: Max: 2550 mg/kg over 10 20 min; give faster in Torsade 2 gm hypotension, bradycardia Procainamide: atrial and ventricular antiarrhythmic to consider for perfusing rhythms ECC Handbook p. 96 Perfusing recurrent VT: IV/IO: 15 mg/kg infused over 30 60 min Recurrent SVT: IV/IO: 15 mg/kg infused over 30 60 min hypotension; use it with extreme caution with amiodarone as it can cause AV block or Increase heart rate: Epinephrine: Drug of choice for pediatric bradycardia after oxygen and ventilation ECC Handbook p. 92 Dose is the same as listed above. Atropine: Vagolytic to consider after oxygen, ventilation and epinephrine ECC Handbook p. 89 Blocks vagal input therefore increases SA node activity and improves AV conduction. IV/IO: Child max: Adolescent max: 0.02 mg/kg; may double amount for second dose 1 mg 2 mg Do not give less than 0.1 mg, or may worsen the bradycardia Decrease heart rate: Adenosine: Drug of choice for symptomatic SVT See ECC Handbook p. 88 7

For injection technique Blocks AV node conduction for a few seconds to interrupt AV node reentry. IV/IO: 2nd dose: first dose: 0.1 mg/kg max: 6 mg 0.2 mg/kg max: 12 mg transient AV block or asystole; has very short halflife Increase blood pressure: Dobutamine: Synthetic catecholamine ECC Handbook p. 92 Increases force of contraction and heart rate; causes mild peripheral dilation; may be used to treat shock. IV/IO infusion: 2 20 mcg/kg/min infusion Tachycardia Dopamine: Catecholamine ECC Handbook p. 92 May be used to treat shock; effects are dose dependent. Low dose: Moderate: High dose: V/IO infusion: increases force of contraction and cardiac output. increases peripheral vascular resistance, BP and cardiac output. higher increase in peripheral vascular resistance, BP, cardiac work and oxygen demand. 2 20 mcg/kg/min tachycardia Miscellaneous: Glucose: ECC Handbook p. 93 Increases blood glucose in hypoglycemia; prevents hypoglycemia when insulin is used to treat hyperkalemia. IV/IO: 0.5 1 g/kg; this equals: 2 4 ml/kg of D25 or 5 10 ml/kg of D10 or 10 20 ml/kg of D5 max recommended: should not exceed D25%; hyperglycemia may worsen neuro outcome Naloxone: Opiate antagonist ECC Handbook p. 95 Reverses respiratory depression effects of narcotics. < 5 yrs or 20 kg: IV/IO: 0.1 mg/kg >5yrs or 20kg: IV/IO: up to 2mg halflife is usually less than the halflife of narcotic, so repeat dosing is often required; Sodium bicarbonate: PH buffer for prolonged arrest, hyperkalemia, tricyclic overdose: ECC Handbook p. 97 Increases blood ph helping to correct metabolic acidosis. IV/IO: 1mEq/kg slow bolus; give only after effective ventilation is established causes other drugs to precipitate so flush IV tubing before and after. AmericanHeartClasses.com CPR 3G (877) 3114CPR (4277) 8